online form

All appointments are requested by email

Please completed the online application form

Request for Information

Who is the appointment for?
Has the patient previously received care at Mayo Clinic?

Patient Information

Please provide patient information as it appears on your passport
* Patient Passport Number
* Patient Last Name
Middle Name
* First Name
Patient Title
* Gender
* Date of Birth (YYYY-MM-DD)
* Address
* Country
* City
Province/State
* Postal Code
* Primary Phone Number
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Alternative Phone Number
+ - -
Fax Number
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* Email Address
Does the patient need an interpreter?

Patient Insurance Information

* Does the patient have health insurance?

Medical Information & Documents

* Describe the primary medical problem or diagnosis for the appointment request
* Requested Department at Mayo Clinic
* Diagnosis Description
Select all relevant reports
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